‘We, Health Workers, Don’t Need Ordinances. What We Need is Trust’

We, in healthcare, cannot be at war with the people of our own country, writes Dr Sumit Ray on violence amid COVID.

Protest image used for representational purposes.

Amid several reports of attacks on healthcare personnel engaged in treating and tracking COVID-19 cases across the country, the Cabinet, on Wednesday, 22 April, approved an ordinance to amend the Epidemic Act of 1897, making acts of violence against health workers a cognisable and non-bailable offence, punishable with prison terms.

How important is this ordinance in the fight against COVID-19? Why is there violence against healthcare workers (HCWs) during this pandemic?

To understand that, we need to understand the history and the sociological context of a pandemic or epidemic. Before analysing this violence and the ordinance, it needs to be reiterated that any violence is unacceptable and must be condemned.

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‘Transactional’ Model of Healthcare Must Change

Violence against healthcare workers, particularly doctors and hospital staff, has been almost endemic in India, the last few decades. This growing trend mirrored the increasing privatisation of healthcare since the 1990s. Though the majority of attacks have been on private establishments, however, very often, government doctors, particularly resident doctors in the frontline of care in emergency rooms and ICUs, have borne the brunt. The reasons for this is multifactorial.

India’s predominantly privatised healthcare system is extremely inequitable and causes high degree of indebtedness among not just the poor, but also the middle class.

Almost 70 percent of healthcare spending in India is out-of-pocket. According to a report of a Parliamentary Standing Committee in 2016, nearly 63 million people are pushed below the poverty line every year because of healthcare debts.

As the contract between private healthcare providers and patients has become more of a business deal rather than service, as is the nature of ‘business deals’ everywhere, everyone wants the biggest bang for the buck.

In this environment, when people are forced to shell out large amounts of money for healthcare and the results are not what they expect, they take to violence. This is somewhat similar to the over-privatised model of healthcare in the US, where the violence is not physical, but, litigational. In this transactional model of healthcare delivery, laws alone might not succeed in changing the increasingly confrontational relationship between healthcare providers and the people. This law goes further to put the two sections at ‘war’.

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How is Nature of Violence Against Healthcare Workers ‘Different’ This Time?

To begin with, the government needs to invest more than a measly 1.2 percent of India’s GDP on healthcare to reduce people’s burden of healthcare expenses. Most countries with a decent public health system in the Lower Middle Income Group (LMICs) to which India also belongs, spends roughly 2.5-3 percent of GDP on public health. In India, that has been an unkept promise for over a decade.

The violence is also related to a lack of training in communication and interpersonal behaviour among medical students and resident doctors.

When high stress situations in the ER or ICU take a turn for the worse, they find themselves inadequately equipped to deal with it.

The nature and the reasons for the violence during this pandemic are somewhat different, however. This violence is directed more towards public healthcare workers, like ASHAs and COVID-19 sample collectors, rather than doctors. This arises from the stigmatisation and ostracisation of patients or suspected patients of COVID-19, and of certain communities along the lines of religion.  This has led to people feeling isolated, threatened and vulnerable.

Also Read: Why Violence Against Doctors Must Stop

COVID is an ‘Invisible Enemy’: A Dangerous Narrative

There is also an associated element of vigilantism against patients/suspected patients, part of a widespread and growing lynch-culture in the country. When governments and healthcare systems talk of the virus as an invisible and untreatable ‘enemy’, it has dangerous consequences.

The lack of understanding, irrationality and fear that it generates, leads a section of people to find a ‘visible enemy’ to attack.

The war rhetoric used by governments has made a difficult situation worse. Historically, bigotry and social ostracisation worsened during pandemics/epidemics and we see the same unfortunate patterns even today.

Yet, in Kerala, where people of all religious and social groups have faith in the governance and unbiased nature of the state machinery, large number of patients, suspected patients and their contacts were traced, quarantined and isolated without attacks on healthcare workers.

In states where there is a lack of trust in the State, and where biases against certain groups are obvious, frontline healthcare workers, seen to represent the biases of the State, bear the brunt of distrust and hate.

This is not new. This is a typical response of a people who have lost faith in the State.

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Politics of Plague & Hierarchy Among Healthcare Workers: What Must Change ASAP

During the plague pandemic in India, the British colonial government brought in the draconian Epidemic Act in 1897, the same law which is being amended now by the ordinance. Measures carried out under this Act included mass sanitation, stopping of social and religious gatherings, social distancing, invasion of private property to search for plague suspects, etc.

As historian and author David Arnold (Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India) says, “Never before had the State in India intervened so directly and forcefully in the lives of the Indian people. This produced a massive backlash from Indians of all classes, who deeply resented the physical inspections and the invasion of their homes, including riots and attacks on Europeans and health workers…”

The healthcare workers in India need PPEs, better facilities and equipment – from ventilators to monitors to adequate number of test kits to care for and identify COVID-19 patients.

There is also a need to reduce hierarchy among healthcare providers.

While doctors are being put up in five star facilities in some states, nurses and other HCWs are getting worse than basic facilities.

We, Healthcare Workers, Can’t Afford To Be At ‘War’ With Our Own People

The government needs to reassure people that it will take care of all its people without bias on the lines of caste, community or religion. It should emphasise the need to stop stigmatising people infected by the virus or suspected of being infected, or those of a certain community or religion.

We, in healthcare, cannot be at war with the people of our own country.

We are battling a pandemic – and are all in it together. We do not need more ordinances and laws to protect us. Individually and through our representative associations there is a need to fight for a better and more equitable healthcare system and care for people with more empathy and without prejudice. If we expect people to accept us to live amongst them during this pandemic, in spite of the fear of transmitting the disease, we too must shed our prejudices against our own people.

(Dr Sumit Ray is a Senior Consultant, Critical Care Medicine, Delhi. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for the same.)